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Reimbursement

Freedom, Independence and Enjoying the Practice of Medicine

A Renewed Approach to Patient-Centered Care

 

Thanks to SCAPA, I was able to attend a very unique conference put on by the Association of American Physicians and Surgeons (AAPS) in Dallas, Texas and I am excited to bring this information back to our members.  The conference was titled, Thrive, Not Just Survive: Building a Healthy Independent Practice Workshop.  The conference targeted physicians, especially independent practice physicians; however, it was applicable to all billing providers and presented a much-needed alternative to the third-party payer system.  The focus of this conference was how to successfully opt out of Medicare, although there were those who opted out of all insurance contracts. 

  

PAs experience the pressures of billing, documenting to justify the billing and avoid audits, PQRS and meaningful use requirements with cumbersome electronic health record systems.  Many of us became PAs with the hope that we would have more time to spend with our patients, only to find out that as our supervising physicians feel the time and money crunch, we inevitably feel it too.  It is nearly impossible to be in health care and not observe the disproportionate amount of time spent documenting, filling out prior authorization forms and battling over the phone with insurance clerks to get medically-necessary diagnostics or medications approved by the third party payer.  This time should be spent with the patient to perform proper history taking and physical exams, as well as building a trusting relationship with the patient.  Instead of being the rewarding profession it should be, medicine is now seeing higher and higher rates of burnout and practice closure.      

On the horizon is a very important, likely very oppressive Medicare transition.  Starting in 2019, Medicare plans to fully implement Medicare Access and Chip Reauthorization Act (MACRA).  MACRA is touted as a value-based plan where providers will receive ratings based on various quality measures, which will ultimately determine reimbursement: providers will either be rewarded or penalized.  Scores will be made public.  The government will have a capped amount that it will allow for total annual reimbursement nationally, so inherently it is a system with “winners and losers.”  It is projected that 87% of solo practices will be adversely affected by this new reimbursement system.  MACRA will require complete access to all patient medical records so as to analyze and audit data freely, thus, compromising patient privacy.  Now is the time for organizations and individuals to speak out about the proposed changes.  AAPA has submitted some concerns to Health and Human Services (HHS) and Centers for Medicare and Medicaid Services (CMS) and is simultaneously preparing for this change.  Michael Powe, AAPA VP of Reimbursement and Professional Advocacy, stated during our most recent reimbursement conference call that this is by far the most significant federal change he has seen in his 24 years in AAPA.  

AAPS has a wealth of information regarding reimbursement, independent practice and Medicare.  I will try to summarize some of the highlights of how to become less dependent upon government reimbursement, as presented at this conference.  As PAs, we can bring new information to our respective practices, as many clinicians may be too busy trying to keep up with all of the regulations and business demands to explore other options.  Fear of the unknown is also a big deterrent to change, but with knowledge, clinicians can regain control of their lives and practices. 

 

Key points and advice from experienced AAPS physicians and lawyers:

1.     Test the waters and get patients used to paying up front by becoming a “non-participating” provider.  As a non-participating provider, your patients will pay you at the time of the visit and you will submit claims on their behalf so that they receive direct reimbursement.  This gets patients used to paying up front and they are able to see the charges and reimbursement flow. 

2.     Find a niche.  Set yourself apart with either becoming an expert in a certain area, offering personalized care, etc.  There were several examples of this, including subspecialty niches, being in an underserved area, and offering discounts for teachers, preachers, and patients wearing spurs!    

3.     Keep debt in check and begin looking for ways to reduce practice expenditures before reducing third party contracts.

4.     Survey Medicare patients.  This serves a dual purpose: it informs the patient of the benefits of an opted-out provider and allows the practice to gain feedback from Medicare patients.    

5.     Sell the concept and inform patients of the money they are saving.  This requires you to be very familiar with insurance plans and reimbursement rates. 

6.     Tap into resources and physicians who have experience with opting out of third-party payer plans. 

7.     Understand that for the vast majority of patients, Medicare will still cover labs, diagnostics, imaging, hospitalization, as well as urgent and emergent care for patients who are seen by opted-out physicians.

8.     There are many ways to structure pay plans.  Two of the most common are the following: A) monthly dues allowing either unlimited or a certain number of visits per year, or B) pay per visit with either flat fees or payments based on complexity or other factors of your choosing.  That’s one of the greatest benefits- providers have the freedom to create a plan that works for them and their patients.     

9.     If you do choose to opt out, ensure that you understand any and all remaining contracts so that there are not any conflicts or repercussions.  Get certified documentation from Medicare of your opted out status. 

10.  This is possible to do even within a health care system. Extra care will need to be taken to contracts and you may want to consult with a lawyer.  

11.  The Medicare opt-out is specific to the provider only, not to the entire practice.  

12.  If you change your mind and want to opt in to Medicare again, you can do so.  Just be aware that there are complexities with terminating the opt-out status. 

 

There are many benefits to opting out of Medicare for both the provider and the patient.  Several speakers shared their practice outcomes from making the switch to an opted-out provider.  Ultimately, they were seeing fewer patients per day with the same amount of revenue.  Additionally, they are spending a fractional amount of time doing paperwork.  One physician estimated her time spent on paperwork was now 2%, versus 50% when she was still a Medicare provider.  Administrative duties and staff are significantly reduced.  One orthopedic surgeon showed graphs of both his and the PAs revenues over time.  As Medicare enrollees, the PA was actually losing money for the practice.  Once they opted out and began direct payment plans, the PA became a money-maker.  Of note, the patients payed 15% less to see the PA.    

Most patients are hoping for a more transparent, less expensive system.  Medicare patients are having difficulty finding providers who are accepting new Medicare patients.  Even if they try to pay out of pocket instead of using Medicare insurance, providers who have contracts with Medicare cannot offer an alternate payment plan.  There was a patient who came to the conference just to implore physicians to consider opting out, thus improving access to care.    

 

Unfortunately, the Affordable Care Act marketplace offers insurance plans that are too expensive for many or plans with high deductibles.  Therefore, patients either remain uninsured or avoid care because of the deductibles.  About half of the insured are spending exponentially more on insurance premiums than the insurance companies are paying out and many young, healthy patients choose not to have insurance altogether.  From personal experience, I can tell you that my family has a Blue Cross Silver plan through the ACA marketplace exchange, and it is the worst insurance I have ever had.  We pay an $800 monthly premium for three healthy individuals with maximum out-of-pocket allowable expenses exceeding $13,000 and 50% coinsurance.  I sincerely cannot imagine how many families afford insurance.  We also have extended family members who are underinsured and are utilizing direct pay providers.  I would imagine we all know someone who has these challenges.  If you haven’t already, I encourage you just to go to the ACA marketplace website and see these plans so that you know what your patients are facing.           

 

There is an increasing distrust amongst patients that clinicians are catering to the pharmaceutical or insurance companies instead of putting their needs first.  When you have a straightforward payment plan, this transparency increases patient trust, patients can budget accordingly and they are more apt to seek preventative and early intervention services.  There are many potential benefits to reducing the “middle man.” 

 

Most of us are not aware that practices have the option to say no to bureaucratic oversight and get back to patient-centered medicine.  I know I wasn’t aware until recently.  While I realize this is unfamiliar and potentially uncomfortable since all of us have only known this sort of payment system, I encourage you to be informed and be advocates for your patients and your chosen profession.  We don’t have to be passive participants in the health care system, as there is no health care system without clinicians.     

  

The Reimbursement Committee coordinates chapter efforts to assure appropriate reimbursement for physician services provided by PAs and serves as a resource to members with practice-related issues as it pertains to reimbursement. It is important to remember that just as Practice issues relate to every PA in the state, each and every specialty may also have its own unique issues related to that particular field of medicine. Could you be a voice on this committee for your specific specialty? Would you be willing to serve along in the STAR (State Advocates for Reimbursement) Network? Please contact SCAPA if you have an interest in reimbursement and payment policy and would like to put your passion to work for your profession right here in South Carolina.

 

STAR Network

 

The State Advocates for Reimbursement (STAR) Network is a collection of PAs at the State level who have an interest in reimbursement and payment policy, and a willingness to research policies and share findings with fellow PAs, State Chapter Leaders and AAPA. "STARs” function as the eyes and ears for the profession by detecting policy changes as they occur.

The Goal of this network is to have one STAR for each major payer in the State. That way the time commitment is kept manageable for each individual within the committee.

Among the tasks STARs will be asked to do include:

  • Monitoring 1 or 2 private payers in the state. This may be accomplished by searching the website for payer policies, which sometimes includes provider protected web pages.
  • Participating in bi-monthly conference calls to share research techniques and findings with PAs across the country.

If you are interested in finding out more about the STAR project, contact Kelly Headley at kheadley07@gmail.com.

 

Please see our STAR Network Resources Page for more information and important resources:  STAR Network

 

Medicare

 

Medicare is a government-administered program providing health insurance to more than 43 million Americans. The Centers for Medicare and Medicaid Services (CMS) implements laws and establishes policies affecting Medicare and contracts with health care professionals to process Medicare claims. Medicare rules require that services by physician assistants (PAs) be reimbursed at 85 percent of the physician fee schedule except in specific billing exceptions ("incident to” and "shared visits billing”). A PA must enroll in the Medicare program by submitting the 855i form, and use his or her National Provider Identifier (NPI) number to alert the carrier to implement the 15 percent discount.

 

Medicaid

 

Medicaid is a program whereby federal and state governments share the cost of providing approximately 58 million needy Americans with health care coverage. To qualify for the program, states must include hospital services, prevention services, skilled nursing and home health care coverage for adults, and prevention and treatment services for children. Unlike Medicare, Medicaid has a state funding component, and allows each state to write its own rules for medical coverage. Therefore, every state may define PA scope of practice and reimbursement rules.

 

Medicaid Bulletin - October 2015

 

Private Payers

 

Nearly all private payers reimburse for services provided by PAs; however, insurers may have different policies regarding how PAs are credentialed, what services PAs may provide, and how services provided by PAs should be billed. In general, when state laws are followed, insurance plans cover PAs providing medically necessary services that are within the scope of PA practice. Many payers request that PAs submit claims for medical services under the physician’s name and provider number and reimburse for the PA’s services at the same rate a physician would receive. Some payers, however, individually credential PAs and ask that claims be submitted with the PA’s name. It’s imperative that the practice employing the PA ascertain the payment policies for each payer with whom they contract.

 

Workers Compensation

 

Worker’s Compensation provides insurance to employers to provide benefits and care to employees injured on the job and benefits to families of those killed on the job. Like Medicaid, Workers’ Compensation, also known as industrial insurance, is administered by each state and, likewise, each state determines its own rules regarding PA reimbursement and scope of practice.


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